<?php
/* @var $this MedicalHistoryController */
/* @var $model MedicalHistory */
/* @var $form CActiveForm */
?>

<div class="form">

<?php $form=$this->beginWidget('CActiveForm', array(
	'id'=>'medical-history-form',
	'enableAjaxValidation'=>false,
)); ?>

	<p class="note">Fields with <span class="required">*</span> are required.</p>

	<?php echo $form->errorSummary($model); ?>

	<div class="column">
		<?php echo $form->labelEx($model,'Are you pregnant and or/ nursing?'); ?>
		<?php echo $form->dropDownList($model,'pregnant', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'pregnant'); ?>
	</div>
<br><br><br>
	<div class="column">
		<?php echo $form->labelEx($model,'Do you have any allergies to medications?'); ?>
		<?php echo $form->dropDownList($model,'allergy', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'allergy'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'If yes, please explain:'); ?>
		<?php echo $form->textField($model,'allergyyes',array('size'=>60,'maxlength'=>200)); ?>
		<?php echo $form->error($model,'allergyyes'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'List all medications you take (Including oral contraceptives, aspirin, over-the-counter medications, and
home remedies:)'); ?>
		<?php echo $form->textField($model,'medical_list',array('size'=>60,'maxlength'=>200)); ?>
		<?php echo $form->error($model,'medical_list'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'List all major injuries, surgeries and/or hospitalizations you have had:'); ?>
		<?php echo $form->textField($model,'major_injuries',array('size'=>60,'maxlength'=>200)); ?>
		<?php echo $form->error($model,'major_injuries'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'lazy_eye'); ?>
		<?php echo $form->dropDownList($model,'lazy_eye', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'lazy_eye'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'drooping_eyelid'); ?>
		<?php echo $form->dropDownList($model,'drooping_eyelid', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'drooping_eyelid'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Glaucoma'); ?>
		<?php echo $form->dropDownList($model,'galucoma', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'galucoma'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'Retinal Disease'); ?>
		<?php echo $form->dropDownList($model,'retinal', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'retinal'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Cataracts'); ?>
		<?php echo $form->dropDownList($model,'catatracts', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'catatracts'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'crossed_eye'); ?>
		<?php echo $form->dropDownList($model,'crossed_eye', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'crossed_eye'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Eye Infection'); ?>
		<?php echo $form->dropDownList($model,'eye_infect', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'eye_infect'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'eye_injury'); ?>
		<?php echo $form->dropDownList($model,'eye_injury', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'eye_injury'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Are you wearing eyeglasses?'); ?>
		<?php echo $form->dropDownList($model,'wearing_eyeglasses', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'wearing_eyeglasses'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'Are you wearing contact lenses?'); ?>
		<?php echo $form->dropDownList($model,'wearing_contact', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'wearing_contact'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'If yes, how old is your lenses?'); ?>
		<?php echo $form->textField($model,'wearing_eyeglasses_old'); ?>
		<?php echo $form->error($model,'wearing_eyeglasses_old'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'If yes, how old is your present pair of contact lenses?'); ?>
		<?php echo $form->textField($model,'wearing_contact_old'); ?>
		<?php echo $form->error($model,'wearing_contact_old'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Type of contact lenses'); ?>
		<?php echo $form->textField($model,'contact_type',array('size'=>20,'maxlength'=>20)); ?>
		<?php echo $form->error($model,'contact_type'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'Are they Comfortable?'); ?>
		<?php echo $form->dropDownList($model,'comfortable', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'comfortable'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Patient Name'); ?>
		<?php echo $form->dropDownList($model,'personalinfo_id', CHtml::listData(

		PersonalInformation::model() ->findAll(), 'id','fname', 'lname'), array('prompt' => 'Select Patient')); ?>

		<?php echo $form->error($model,'personalinfo_id'); ?>
	</div>
<br><br>
	<div class="row buttons">
		<?php echo CHtml::submitButton($model->isNewRecord ? 'Create' : 'Save'); ?>
	</div>

<?php $this->endWidget(); ?>

</div><!-- form -->